After years of honing skills to care for high-risk patients, physicians are moving, quitting, or retiring as a direct result of the current liability crisis. Some are marching on legislatures, while closing their clinics in protest. Every minute that doctors spend engaged in lobbying, they are not refining or using their medical skills for the benefit of patients. An army of wise, experienced doctors is withdrawing prematurely from practice. Physicians whose families have a time-honored practice tradition are discouraging their offspring from entering medicine. The pool of medical school applicants is shrinking. The best and the brightest are choosing not to live with the vulnerability associated with the emotional and financial destruction of litigation. After 25 years of studying physicians as a stressed tribe, we are convinced that the human cost of practicing medicine is becoming unbearable.

Patients, the economy, and professional relationships are all negatively impacted by the pandemic of practitioner fears and defensive medicine. Doctors now routinely order more tests, including uncomfortable, invasive or low return tests, which will be deemed “essential” by experts if there is later litigation. They avoid performing some procedures because of risk of complications is too great, and others because they will need to rely on members of a team to perform them; they will then be deemed to be responsible for the performance of all members of the team.

With liability insurance premiums soaring up to 400% in several states, the number of practicing obstetricians has decreased so dramatically that those who remain are overwhelmed and risk rapid burnout. Trauma centers are closing because hospitals and surgeons cannot bear the malpractice premiums. In at least 20 states, emergency physicians report that liability coverage is either unobtainable or unaffordable. Hospitals are already planning to close emergency rooms. Physician shortages for those in rural areas and inner cities will worsen most dramatically, as physicians retreat from liability risk in those areas where backup is not available, or where “jackpot justice” prevails. Most experts predict that in 10 years, only federalized physicians will practice in high-risk ob/gyn or other litigation-prone specialties or locales. Patient care costs will rise and services will be even more limited if these liability-associated problems are not resolved.

We have conducted “psychological autopsies” on two physicians who suicided as a result of receiving a claim for malpractice. There was no pre-existing pathology. The profession, and society, lost two physicians needlessly. Rarely a week goes by without some doctor calling us asking for help in transitioning out of medicine. More often than note, the reason is the current malpractice climate.

Threatened doctors withdraw from innovations in treatments, constructive feedback, compassionate patient care, and their own self-care. As the job of practicing medicine dissipates, ambiguous feelings towards patients and their families arise. Many physicians now report viewing patients as potential litigants instead of real people. More and more referrals to our center arise from behavior that is prompted by fear and/or frustration about litigation. This may take the form of depression, anger, addiction, physical illness, or disruptive behavior.

Non-physicians often view litigation as part of the cost of doing business. Even with a worst-case scenario, they expect their company to share and/or defray the expenses. Physicians view their work as integral to their very beings, so the emotional reaction is quite different.

The impact of a medical malpractice suit on the physician, and on his or her family, produces the symptoms of medical malpractice stress (MSS), which may include physical and emotional symptoms of remarkable severity. Physicians perceive a suit as an assault on their integrity. It hits us in the heart. As a result of vulnerability (especially feelings of shame) brought on by litigation, most physicians experience a loss of empathy.

Physicians are suffering from extreme expectation mismatch. They have delayed gratification for 11+ years of training, and now are confronted with threats and coercion from all corners. They expected support, respect, attentiveness, cooperative patients, and autonomy. They did NOT expect adversarial relations, burgeoning paperwork, ceaseless handwork, declining reimbursement, eroding autonomy, and multiple levels of scrutiny, with the specter of employment, licensure, status and/or monetary loss.

They also did not expect non-collegial, passive-aggression from peers. Perhaps most devastating, they did not expect cooptation and pressure to lie so as to help their patients obtain needed care. At this point in history, practicing medicine is a cacophony of insults. This clash causes an epidemic of burnout. Even younger doctors now feel and report compassion fatigue, formerly a late sign of burnout. Doctors’ folklore has become cynical, sarcastic, and negativistic. Obstetricians and others constantly ask us, “Where has the joy gone?”

What should we do about the epidemic of liability stress, and why should we care about doctors? Caring for our caregivers is good medicine for our society.

At the first aid level, we must teach our physicians how to prevent and cope with assaults on their integrity. We must teach them what to expect, including the massive emotional responses to a lawsuit and its process. We must optimize medical quality assurance systems so that litigation does not remain the de facto mechanism for dealing with mistakes, errors, maloccurrences, and the unpredictability of human responses to medical care. We must facilitate no-fault compensation, mediation or arbitration by medical experts, and honesty (allowing apologies), so that open communication is unencumbered by evidentiary and other rules of legal procedure.

Expectations must become more realistic so that patient-physician partnerships are the norm in healthcare negotiations. Doctors must become more comfortable with saying, “I don’t know” so that each of the fallible actors in the system (doctor, patient, family, and facility) can take ownership of what we can and cannot control. Patients must become more comfortable with asking, “Why?”

Finally, we must look at the current epidemic of practitioner burnout, discouragement, disillusionment, and malpractice stress as a clarion call that the system is critically ill. We must champion interventions that promote partnership, cooperation, teamwork, and mutual responsibility. If we simply continue down the present pathway, the system will continue to deteriorate, and patients will become the ultimate victims.

John-Henry Pfifferling, PhD                                                       Louise B. Andrew, MD, JD

Director                                                                                    Associate Director

Center for Professional Well-Being

Durham, NC

(919) 489-9167

Web site: http://www.cpwb.org

Reprinted by permission of NC Physicians Health Program from Fall-Winter 2003 issue of Metamorphosis.